ADA Paratransit Application

Transcription

1 ADA Paratransit Application Please mail, or fax your completed application to: Michiana Area Council of Governments (MACOG) 227 W. Jefferson Blvd County-City Building South Bend, IN Phone: (574) Fax: (574) Revised 1/26/2016

2 Overview The purpose of this application is to provide an opportunity for you to describe how your disability prevents you from being able to ride the Interurban Trolley system. If you have difficulty answering any questions on the application or if you need assistance completing this form, please call MACOG at (574) Please complete this application as thoroughly as possible. te that the application is printed on both sides of each page. The more complete and accurate information you provide, the better MACOG will understand your abilities and travel challenges. If a question does not apply to you, please write t applicable or N/A. Information contained in this application will be kept confidential and shared with the professionals involved in the evaluation of your eligibility for MACOG or others designated on the Application Certification and the Authorization to Release Medical Information forms. MACOG will mail you an eligibility determination within 21 days of the date that MACOG receives your application. Appeal Process Persons whose application is not found eligible may appeal the decision in writing, within 60 days of the date of their determination letter. Send appeals to: Michiana Area Council of Governments (MACOG) 227 W. Jefferson Blvd County-City Building South Bend, IN The Elkhart/Goshen Transit Advisory Committee will review the eligibility documentation and make a final decision on eligibility status. This review will be concluded within twenty-one working days of the date the appeal was received. The person making the appeal has the right to appear at this review. 1

3 PART A Contact Information Please Print: Last Name First Name Middle Name Home Address: Address City Zip Code Mailing Address (If different from Home Address): Address City Zip Code Contact Information: Daytime Phone Evening Phone Cell Phone Fax Personal Information: Male Female Date of Birth: / / MM DD YYYY Emergency Contact: Name Relationship Daytime Phone Evening Phone Cell Phone 2

4 PART B Paratransit Service Certification Please answer the following questions in detail your specific answers to the questions will help us in determining your eligibility. Disability or Health Condition Information 1. Please specifically name disabilities or health related conditions that PREVENT you from using the Interurban Trolley public transit system. 2. Briefly explain HOW your disabilities or health related conditions prevent you from using the Interurban Trolley public transit system. 3. Do the conditions you describe change from day to day in a way that affects your ability to use public transit?, good on some days, bad on others., doesn t change. Don t know 4. Are the conditions you described: Permanent Temporary Don t know If temporary, how long do you expect these conditions to continue? 3

5 PART B Paratransit Service Certification 5. Do your disabilities or health related conditions prevent you from understanding bus schedules, paying fares, transferring buses, or when to get on or off the bus? 6. Do your disabilities or health related conditions prevent you from easily seeing steps and curbs, route names on buses, or trolley stop signs? Mobility Information 1. Do you use any of the following mobility aids or specialized equipment? (Check all that apply) Cane Power Wheelchair Manual Wheelchair White Cane Service Animal Communication Devices Power Scooter Crutches Walker Leg Braces Prosthesis Portable Oxygen Tank Other Aid: Required of all wheelchair users: Height of Wheelchair: Width of Wheelchair: Weight of Wheelchair: Combined Weight of Applicant & Wheelchair: 4

6 PART B Paratransit Service Certification 2. Do you travel with the help of another person? Always Sometimes Never If always or sometimes, what type of help do they provide? 3. Can you travel 3 blocks with your usual mobility aid and without the assistance from another person? 4. Can you climb three 12-inch steps without assistance from another person? 5. Can you wait outside without a seat or shelter for 10 minutes, if the weather is good? 6. Can you communicate with a bus driver with or without an aid (such as a picture board or route ID cards)? 7. Can you travel up or down a gradual hill on the sidewalk, if the weather is good? 8. Can you cross the street, if there are curb cuts? 9. Do you ride the Interurban Trolley public transit system?, regularly, occasionally, I have never used the Interurban Trolley, not since the onset of my disability 5

7 PART B Paratransit Service Certification 10. Are you able to get to and from the bus stop nearest your home? Sometimes Don t know, never tried it If no or sometimes, explain why: 11. Are you able to grasp handles, railings, coins, or tickets while boarding or exiting a transit vehicle? Sometimes Don t know, never tried it If no or sometimes, explain why: 12. Are you able to maintain balance and tolerate movement of a public transit vehicle when seated? Sometimes Don t know, never tried it If no or sometimes, explain why: 13. Would you be able to get on or off a public transit bus if it has a lift, ramp, or a kneeler that lowers the front of the bus? Sometimes Don t know, never tried it If no or sometimes, explain why: 14. Please add any other information that you would like us to know about your mobility. 6

8 Applicant Certification I certify that I have been truthful in answering this form and that the information that I have provided is correct. I understand that the purpose of this application is to determine if I am eligible to ride the paratransit system. I understand that knowingly falsifying the information will result in denial of service. I understand all information will be kept confidential, and only the information required to provide services I request will be disclosed to those who perform the services. I understand that an eligibility determination will be made within 21 days of the date that MACOG receives my application. I understand that if my application is not found eligible, that I may appeal such determination within 60 calendar days and that I will be advised of the procedures for such an appeal. I understand that it may be necessary to contact a professional familiar with my functional abilities to use public transit in order to assist in the determination of eligibility. Applicant s signature: Date: Did someone help you in filling out this form? If yes, Name: Phone: Relationship to Applicant: Address: City: State: Zip Code: Daytime Phone: Signature: Date: 7

9 PART C - Healthcare/Social Service Professional Verification In order for MACOG to evaluate your request, it may be necessary to contact a professional to confirm the information you have provided or to answer any additional questions about your functional abilities to ride public transit. Please identify a person who could document your disability by completing the following information and authorization form. The following professional is most familiar with my disability and my functional abilities to ride public transit : Professional s First and Last Name Address City Zip Code Phone Fax Check the appropriate box to identify professional relationship: independent living specialist physician chiropractor physician s assistant mental health counselor psychologist or psychiatrist nurse practitioner registered nurse occupational or physical therapist rehabilitation counselor ophthalmologist or optometrist social worker orientation and mobility specialist vocational rehab. counselor other: I authorize the release of required information to MACOG for certification. Applicant s signature: Date: 8

10 PART C - Healthcare/Social Service Professional Verification ADA Paratransit Application Dear Professional: Your client/patient is requesting eligibility for The Interurban Trolley s Americans with Disabilities Act (ADA) Paratransit service. Your professional relationship with this applicant uniquely qualifies you to help clarify his or her functional abilities and limitations. These guidelines may help you understand the type of information we need in order to determine the applicant s eligibility for paratransit. ADA paratransit eligibility is based not just on the presence of a disability, but on the effect that the disability has on the person's ability to use the fixed route service. The eligibility determination focuses solely on: Functional ability to independently perform the tasks necessary for bus use including: getting to and from the bus stop, getting on the bus, riding the bus, and understanding how to navigate the system in a variety of environments. A diagnosis by itself does not qualify an individual for paratransit service eligibility. Whether the individual is prevented and unable from performing these tasks, as opposed to the task being more inconvenient or difficult. Whether the individual can perform these tasks all of the time, only under some circumstances, or if the disability would always prevent the individual from performing these tasks. Please note that all fixed route buses are equipped with lifts or ramps. Fixed route buses offer accessibility features like priority seating for seniors and individuals with disabilities, secure wheelchair tie-downs, etc. The information you provide along with the applicant s information will enable us to make an appropriate determination for eligibility. All information will be kept confidential. Thank you for your assistance. If you have any questions, please feel free to call us at (574)

11 PART C - Healthcare/Social Service Professional Verification Applicant s Name: Date of Birth: 1. In what capacity do you know the applicant? 2. How long have you known the applicant? 3. When was the last appointment you or your agency had with the applicant? 4. Please describe the nature of the disabilities or health related conditions that PREVENT the applicant from using the Interurban Trolley public transit system: 5. Briefly explain HOW the applicant s condition prevents them from using the Interurban Trolley public transit system. 6. Are the applicant s conditions described above: Permanent Temporary If temporary, how long do you expect these conditions to continue? 7. Does the applicant s disability or health condition change from time-to-time in ways that affect his or her mobility? If, please describe: 10

12 PART C - Healthcare/Social Service Professional Verification 8. If the applicant s disability affects his or her cognitive skills, please answer the following: Can the applicant: Give his or her phone number upon request? Recognize landmarks and/or destinations? Ask for and follow directions? Safely travel in the community? Problem solve in unexpected situations? Clearly communicate needs? 9. Does the applicant use any type of mobility aid? If, what type of aid: 10. Does the applicant travel with a personal care attendant? Sometimes If or sometimes, please describe: 11. If this applicant is currently on medication(s), will the side effects of this significantly reduce or hinder their ability to independently ride the accessible Interurban Trolley system? If, please describe: 12. Would extremes in temperature affect this applicant s ability to ride the accessible Interurban Trolley system? If, please describe: 11

13 PART C - Healthcare/Social Service Professional Verification 13. In your professional opinion what other factors related to the applicant s disabilities affect his or her ability to ride the Interurban Trolley public transit system? I have reviewed all of the information contained in this application and herby certify that all of the information is true and correct to the best of my knowledge and ability. Your Name: Title: Agency or Clinic: Address: City: State: Zip Code: Phone: Fax: Signature: Date: Please mail, or fax your completed form to: Michiana Area Council of Governments (MACOG) 227 W. Jefferson Blvd County-City Building South Bend, IN Phone: (574) Fax: (574) macogdir@macog.com 12